Mitral valve prolapse syndrome, chronic orthostatic intolerance, and orthostatic tachycardia symptoms are each names that reference postural tachycardia syndrome (POTS). POTS is not a new illness. It is caused by a malfunction of the patient’s autonomic nervous system (ANS).

The autonomic nervous system (ANS) governs the involuntary inner workings of our body through five separate but related branches. They control functions such as heart rate, blood pressure, digestion, temperature control, bladder control, sweating, and the fight-or-flight response to stress. The two most famous branches are called the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS). The ANS branch is regulated by neurotransmitters and hormones like dopamine, norepinephrine, epinephrine (also called adrenaline) and acetylcholine. Any illness caused by dysfunction of the ANS is collectively called dysautonomia.

POTS is a subset of dysautonomia where orthostatic (blood pressure) intolerance is associated with the presence of excessive tachycardia (fast heart rate) on standing. It is believed to be caused by central hypovolemia.

Between 75 and 80 percent of POTS patients are female and of menstruating age. Most male patients develop POTS in their early to mid-teens during a growth spurt or following a viral or bacterial infection. Some women develop POTS or tachycardia symptoms with pregnancy.

Physiology of POTS

When lying down, 25 percent of our blood lies in our chest cavity. Upon standing, 500-1000 cc of blood is pulled from our chest to the abdomen and legs by gravity. To maintain adequate blood profusion to our brain and prevent fainting, the SNS is automatically activated, with norepinephrine released by the brain. This hormone travels to the heart and peripheral blood vessels, narrowing blood vessels and increasing the heart rate. Blood flow to the brain is increased. Without norepinephrine, one simply cannot maintain an upright position for long in day-to-day living. Many of the POTS or tachycardia symptoms come from this inability to move the blood quickly to the brain.

Epinephrine, another hormone, also plays a part in normal daily life, though in a much lesser degree. It is primarily released when the body is under severe stress. As part of the fight-or-flight response, epinephrine is the body’s last response to stress. It acts to supply blood to brain and muscle in order for us to survive. It is under the control of the adrenomedullary hormone system.

SNS activation in normal people causes the normal heart rate to increase transiently by 10-15 beats per minute along with a very slight increase in blood pressure on standing. Instantly, an automatic vessel dilatation occurs and blood pressure and heart rate returns to normal. In some people, these activation and feedback mechanisms fail, altering the first increase in profusion and subsequent normalization of blood to the heart and brain. This is when the POTS and tachycardia symptoms surface. Blood pressure falls (orthostatic intolerance), with a compensatory rise in heart rate (tachycardia) when it is too fast.

Tachycardia Symptoms

Remember that as a syndrome, POTS is a collection of symptoms. The symptoms are widespread throughout the body because of the all-encompassing effect of the ANS internally. No organ system can fully escape. You don’t need to have all the symptoms to be diagnosed. They can include:

Light-headedness or dizziness upon standing or even with prolonged sitting. Some describe it as a sense of almost fainting. Approximately 30 percent of people with POTS experience syncope.

Fatigue and lethargy. Overwhelmingly the vast majority of POTS patients experience severe fatigue. This can last for a considerable time after a bout of POTS symptoms.

Fast heart rate or palpitations. There is also a sense of heart pounding commonly associated with this. In severe cases, tachycardia symptoms such as atrial fibrillation and supraventricular tachycardia can be triggered.

Anxiety is very common. This can be accompanied by chest pain.

GI problems, such as nausea, bloating, cramps, vomiting, diarrhea, and constipation. The gut is irritable. Many are told they have irritable bowel syndrome.

Brain fog. This can happen before or after bouts of POTS, and may reflect blood profusion issues to the brain.

Shakiness and hypoglycemia. Some have concurrent low blood sugar and related symptoms after a bout of POTS.

Headaches. Both vascular and migraine type headaches can be experienced. They tend to be better when lying down and worse in an upright position.

Shortness of breath. Patients can feel breathless when standing or during slight exertion.

Excessive or reduced sweating can be seen if other branches of the SNS are involved that regulate sweating.

Visual problems. These can be described as excessive glare, blurred or tunnel vision.

Diagnosis of POTS

If your doctor suspects POTS, a tilt table test is ordered. You lay down on a table, which is then tilted while cardiovascular biomarkers are measured. In adults, POTS is clinically diagnosed when there is a heart rate increase of 30 beats per minute (bpm) or more from baseline, or over 120 bpm within the first 10 minutes of standing in an upright position. Unfortunately, many times the results can be inconclusive or borderline.

While the diagnostic criteria of POTS focuses on the abnormal heart rate increase upon standing, sufferers usually present with a wide set of symptoms beyond blood pressure and rate irregularities. Some POTS patients have no blood pressure dysregulation on standing. Many have high levels of plasma norepinephrine while standing, reflecting increased SNS tone. Norepinephrine acts on the brain and triggers anxiety.

Remember that a person with POTS is stressed every time she/he moves or stands. There is a constant over-release of epinephrine and norepinephrine. It is for this reason that POTS is so often misdiagnosed as anxiety.

The key to proper diagnosis of POTS should factor in the many possible associated symptoms to form a complete clinical picture of an overall autonomic nervous system in disarray.

As with any syndrome, the continuum of dysfunction varies from mild to severe. Those with mild symptoms lead normal lives. In severe cases, even mundane daily activities such as eating, walking, and bathing can be problematic.

Approximately 25 percent of POTS patients are disabled and unable to work.

Different Types of POTS

To better describe the pathophysicology of POTS, it can be grouped in various ways, such as primary (unknown cause) and secondary (caused by something else) POTS, hypovolemic POTS (associated with low blood volume), partial dysautonomic POTS (associated with a partial autonomic neuropathy), and hyperadrenergic POTS (associated with high levels of norepinephrine).

Hyperadrenergic POTS

About 20-30 percent of POTS patients fall into this group. It is characterized by a high normal level of plasma norepinephrine in the supine position, while the upright norepinephrine is usually elevated (>600 pg/ml). As the name implies, it is caused by an uptight sympathetic nervous system. In some subjects, this hyperadrenergic response may be a compensatory reaction to either hypovolemia or peripheral dysautonomia with venous pooling.

Hyperadrenergic POTS has a strong familial link, and is associated with light sensitivity, stress intolerance, adrenergic urtricia, and medication sensitivities.

Conventional Treatment of POTS

Treatment of POTS should be directed at the underlying cause as the top priority and long-term solution. Unfortunately, root causes usually evade detection without a very detailed history. Most physicians trained in Western medicine tend to focus on symptoms control as follows:

Use of firm compression support socks (compared to mild compression socks, for varicose veins) can avoid blood pooling in lower extremities.

Avoidance of diuretics such as coffee, tea and medications with that effect.

Focus on reclining exercises such as rowing instead of upright exercise such as running.

Prescribe medications such as Fludrocortisone, Adderall, Pyridostigmine, Benzodiazepines, Beta Blockers, ProAmitine (Midodrine), and Clonidine, SSRIs such as Prozac or Zoloft, and Dexedrine. In severe cases, Florinef may be considered. Beta blockers and calcium channel blockers can be used to reduce high resting heart rate.

72 Comments

heart rate increase, if excessive, lead to reduce volume output from the heart as there is less time to fill the heart chambers full of blood between each beat. reduce blood flow to head can lead to dizziness.
Dr Lam

I was recently diagnosed with POTS and was prescribed Corlanor (ivabradin). My doctor had me wear a ZIO patch for 7 days. According to my doctor my heart was up and down and diagnosed POTS. However, I asked him about the tilt table test and he said it was not needed and I have POTS. I am also suffering from fatigue syndrome which really hit me bad in the last week. My question is…should I insist on having a tilt table study to rule out POTS and side fatigue syndrome? also do you recommend any doctors in Los Angeles? I am currently seeing a doctor in los angeles who specifically treat POTS. Please help

POTS is largely a symptom of an underlying problem in a setting of AFS. Tilt table test is the gold standard but not every clinician feel it is necessary. Suppressing POTS symptoms long term can be very negative. It is easy to patch symptoms but your focus should go deeper. We are just outside of Los Angeles and have a telephone program that may serve you well. You can call for more info.

POTS is not a disease except when there is organic problems with the nodes. In the setting of AFS, the majority of the time is due to sympathetic overtone. That is good news because when AFS resolve, the POTS usually gets better. Unfortunately, many get worse because thy made it worse not knowingly.

I have been diagnosed with POTS, and have a severe form where I am blacking out or severely dizzy every time I stand, plus head aches, nausea and fatigue – Please can you help me with a recovery program?

thought I had astroke in April,after 1 1/2 yr of gastro problems,started taking kyogreens 2 wks ago with aloe,mag malate,zinc and enzymes,now having normal BMevery morning.i am scared to death as have seen 10 drs cardio says orthstatic heart is not due toheart but something else,endo just told me my A! C is at 5,lost 21 lbs in last month feel so bad ,bp is high and so drug sensitive always so am on hydralazine as a lsst resort,still having sweats and someortho heart…can Iget helpwith my autonomic system before its too late?

Autonomic system dysfunction can be reversed if you first trace to the root cause and find out what is the root issues. Whether it is adrenal driven, neurotransmitter, or something else, that should be your focus. Conventional medicine unfortunately does not focus on this and so you may have to do a lot of homework yourself.
Click Postural Orthostatic Tachycardia Syndrome (POTS) & Adrenal Fatigue Syndrome for more information.

Autonomic dysfunction really can hit any organ. Besides POTS, my pancreas and parts of my small intestine do not release the enzymes needed for proper digestion. This would include whatever it secretes for you to be able to absorb B3 (Niacin). You need B3 to activate B5 to pull cortisol into the target organs. Hence I presented with every symptom of adrenal failure but had cortisol levels that were sky high. (Kinda like not having enough insulin to pull in glucose, except I had no B3 to pull in cortisol). You can make 50% of the B3 you need out of the amino acid tryptophan. But you have to have a high metabolic rate to produce enough. I was slightly hypothyroid and couldn’t convert tryptophan to B3. I went through 5 endocrinologists before I found one that understood this and put me on Cytomel (T3) along with synthroid. Now I have a great B3 level, cortisol levels are normal, and I’m off prednisone!

my name is Alex, I am 22 years old and I live in Greece. I found your website through another website that has to do with POTS syndrome. Of course I’m not waiting a diagnosis via e-mail but I want to hear your advice because I do not know what to do.
In all of my life, I have been very anxious , worrying for everything and having many psychosomatic symptoms(like mild dizziness) that could not be explained by any medical exam. When I forgot about them, everything was OK.Some times I suffered from panic attacks in special cases, like when I sat university exams .
The last half year, sometimes I was feeling my head extremely light when I was attending a course, but when I stood up everything was OK. But two months ago, I experienced a panic attack again in an university exam. Two days later, when I was on the bus to go to the univeristy(thinking of the panic attack), I suddenly felt that I will fall. When I got off, I felt very strange. I walked and I felt that I did not have the control of my self, like some other moving me and a feeling that the floor was moving right , left, up and down. These feelings have not stopped even today. Sometimes I also experience shortness of breathing and a kind of tightening in the throat, head and abdomen. I had many exams and everything was OK. I can walk long distances, and I don’t feel that I will faint, just that someone pushes me and I will fall or the floor will absorb me(sometimes like walking on an earthquake). Some day, I realised via a website that there is a syndrome called POTS and many of my symptoms belonged to the diagnostic criteria. I visited many doctors and noone knew about it. There is no pots specialist in Greece at general,Finally, I found a cardiologist who knew about it but never had faced a patient with this. He did me a stand test and my heart pulse increased +32 (90 to 121) from laying down to standing up. I was terrified because 30 rising is the criterion for a POTS diagnosis but he told me that the fact I am tall and burly ( 6 feet and 4.77 inches tall and 253 lb in weight) could provoke such a rise. His wife, who is a psychiatrist told me based on my anxious background information that because of extreme anxiety, I provoke all these to my self and suggested me the antidepressant Zoloft. Now I feel that I can control my head but not my feet and instability remains when walking. What do you believe? Could this rise happen from anxiety disorder or it’s certainly POTS?
Thank you in advance.

POTS in cases like yours are generally secondary, meaning there are underlying triggers. That is where you attention and focus should be. We do see many POTS like symptoms in AFS and that is where you should also consider. Unfortunbately, this is not something conventional docs are alerted to. I cannot tell you what is appropriate at this time because much detail is missing, and the only way to get to the root is by detailed history which will tell the story.
anxiety can trigger POTS also , but the clinical picture is different.

I’ve been very tired and stressed for the last 8 years. I’ve really struggled at work, it’s long and I deal with things 7 days a week often from early until late at night. I always feel like I have social anxieties and panic before important meetings or inspections to the point of almost vomiting.

I’m just experiencing my first debilitating what I presume is pots after exercising too hard a week ago. I felt really good while exercising but should have known better. I can’t stand up without my heart racing from 55-60 to 100-125 and it’s rather frightening. I’m also extremely fatigued and have been since 2 hours after exercising seven days ago now. At the time if just started 750mg of 20% olive leaf extract at night for 6 days and had taken one half teaspoon on l-glutamine powder just before I crashed. I’d been taking 3000iu of vitamin d3 spray for a few weeks. I stopped everything now.

Most things have made me feel worse afterwards and I’ve tried a lot from iodine,probiotics, omega 3&6, probiotics and even did a 5 day fast (I’ve been worse since the fast but had a much clearer head during it)

I’d finally been referred to a chronic fatigue clinic on July 21st and they’d suggested I might have lots but if not heard of it. I did some home tests and the two days after the appointment I had a 40 bpm increase in the first minute from standing but only felt a little tired those days. When I retested a few days later it was normal.

I’ve never really dealt with stress well and many years ago I had a 24 hour urine collection to check for adrenaline but it came back ok. I wasn’t fatigued then though.

I have a great uncle on my mothers side who had guillian barre syndrome twice.

I’ve always been able to work long hours and was generally quite well and fit until 2008. That when I think my story truly begins.

In 2008 I’d picked up a poorly patient from a house he was visiting and brought him back to the care home I run. He had symptoms of a virus but recovered well. My self and a colleague both became unwell within the next week. Just to confuse things I’d also been working on a sewer and pulled a nappy(diaper) from it and then got sprayed in sewage and cut my arm.

When I got a high fever the docs thought it was from the sewer and gave me multiple antibiotics. I was ill for 8 days and literally thought i was never getting out of bed again. I had what felt like electric shocks and panic during the illness. On the 9th day I felt much better. I felt amazing but that evening I lost feeling in my feet and panicked. Within 10 minutes I was pinned to the floor unable to move after the loss of power washed right up my body. I ended up in A&E but the feelings and power came back within an hour. What I was left with was fatigue, slow nerve responses (there was a momentary delay in my legs and arms moving) I lost words, some memories and had to take it very easy.

Doctors just didn’t seem to care for a long time and I gave up.

Even when I took my pots findings to the GP he didn’t even check my bp. He suggested a 24hour Ecg and asked me to return in 13 days for it.

I worried a lot and ended up calling an ambulance 2 days later after waking with a pounding heart even though it was 61bpm my home bp machine got a bp of 174/124 and my legs began to shake. That was very unusually as it normally reads 135/60. My resting pulse has always been 49-60.

The ambulance got my bp at 135/80 I guess I relaxed once they arrived.

At hospital my ecg was normal, bloods were ok but there was no disputing my pulse races when I stand up. It only happens when I stand but does increase a bit when I sit.

I’d never considered pots until the specialist OT mentioned it at my first chronic fatigue appointment but over the years when I’m very tired I’ve often needed to sit down or bend my legs and lower myself while resting against a table. I’m male, 45, very unfit, 1.68m and 90kg.

Even the chronic fatigue clinic has 9 weeks between my first appointment and the next on the 8th of September. Waiting is very stressful and so it reading the Internet as its full of doom and gloom and people with lots of problems. (I guess those who recover simply don’t post on forums)

I’m off work but it’s my family company and its struggling so the stress isn’t totally gone. The staff and family are keeping things running in my abscence but I feel guilty.

I must also add the the reason I’ve tried various therapies ie iodine, mastic gum, olive leaf extract is because I’ve always felt I had a lingering infection due to the fatigue and abdominal rumblings and constipation or very watery smelly stools immediately after eating a late meal if I’ve missed lunch.

I paid for private Lyme Eliza testing because the sewer I worked on was in the Lake District. (I never had a rash)

The results were ‘negative’ but B.burgdorferi IgG was shown as 8.6 au/ml but the positive is >15 on their test so also interpreted as negative.

I had a positive test for hpylori and the antibiotic protocol that helped a lot with my gut and greatly reduced the loose stools. It’s mainly constipation now but even that’s helped a lot but eating porridge every day for breakfast.

I feel like I’m losing my mind. I have two young children and a great wife but I can tell she’s struggling because she’s often tearful and clearly stressed by it all.

your body is weak, and when survival is at stake, the body activate the sympathethic response . This can account for many of your symptoms which is quite common in a setting of AFS. If your work up is totally negative, you need to consider this as matters will tend to get worse if you dont reverse. Good news is that it is often reversible. Click Postural Orthostatic Tachycardia Syndrome (POTS) & Adrenal Fatigue Syndrome for more information.

Hello. My heart rate increases a lot upon standing and minimal exertion. This morning after my shower it was 130. I just got up and went to the restroom and it was 136. It does not always do this. I am currently weaning off a low dose beta blocker because my cardiologist feels that I don’t need it. He performed a tilt table test on me and I blacked out but he said it wasn’t POTS but it was neurocardiogenic syncope. If it’s not POTS then why does my heart rate jump up like that? Could this be anxiety? The only time I’ve blacked out was during the tilt table test.

the line between neurocardiogenic syncope and subclinical POTS is fine. the underlying physiology is same and varies only on the degree of the autonomic reaction to postural changes. you need to look at the big picture and see what else is going on. Single focus will often not be sufficient to really get to the root problem.

When I stand up after taking a hot bath, I have a lot of dizziness and feel light-headed. Baths are the only thing that reliably reduce my pain, as I do not like taking pain killers (due to nausea and constipation issues). Will treatment for POTS help these feelings as well? I try to stand slowly, but it doesn’t always work.

there are different types of POTS , so you have to first know what kind you have. Having POTs like symtpom after hot bath may be due to blood pooling, and that means the underlying autonomic nervous system may be in trouble. The most commonly associated with AFS is adrenergic type, and you can support the body in calming the POTS with adrenal breathing exercise. Click CD – Adrenal Breathing Exercise for more information. IF that is insufficient, then you need natural compounds to help.

I’ve stayed in the hospital several times, I’ve seen dozens of doctors, changed my diet, but no one understands the condition beyond diagnosing me.
I believe I have HyperPOTS with severe sound/light sensitivity, but I swing from severely fatigued to agitated and feeling like I’m having a panic attack.
I’m in home Physical therapy now which has helped to reduce some of the symptoms. We are trying to incorporate your Ti Chi as I get stronger.
Is there anyone you recommend in the Atlanta, GA area who is treating POTS successfully? What else can I do, this has changed my life.

There are many components to POTS that can be supported nutritionally. Our program is unique because we deal not only with the problem on a physiological but also a functional level. The key is to understand the really deep underlying root cause. POTS in and of itself is just symptoms of underlying discontent of the body. A detailed history by phone is needed .

Hi,I think my daughter (17yrs)has pots but the cardiologist in nz disagrees.she suffers leg and chest pain every day, hand tremors, fatigue, exhaustion when exercising,numbness, dizziness, her tilt table went from 65-115 but not a lot of change in BP, was between 100/50-109/75. Her 24 hr monitor went up to 166 while she was working on checkout. Cardiologist today said its not pots because her BP is ok. What do you think please???? We need answers

Deidra I would get a new cardio Dr. I have Hyperandergenic Pots, and my blood pressure does not always fluctuate a great deal. The diagnosis is that the heart rate increases at least 30 beats per minute. Based on the tilte table alone is enough for pots diagnosis. There are multiple sub groups within pots. It took me 7 specialist before I found one that truly understands this syndrome. Find a specialists that treats pots, don’t give up help is out there!

My daughter has been diagnosed with PoTS. She has EDS. She also has high catecholamine when standing, has sleep attacks that look like she has narcolepsy. Would these attacks be because of raised catecholamines when standing? She is sensitive to stress, attacks occur when surprised or stressed.

catecholamine is a class of chemicals that include dopamine, norepinephrine, and epinephrine. These compounds, when excessive, can trigger POTS. It could be the other way around as well because once you enter the positive feedback loop, they feed on each other and eventually the body becomes unstable.

My daughter was diagnosed with Pots syndrome is October. She recently was hospitalized after a seizure upon wakening in the morning. After this she could no longer bare weight and is slowly regaining her strength in her legs. She is starting physical therapy however her neurologist thinks her inability to ambulate is psychosomatic. Could you give me some insight into this?

What you describe actually is quite complex. Seizures are not normally assoicated with POTS unless there are underlying dysautononomic issues. A detailed history by telephone is required and if one digs deep enough,clues are often present. that is well beyond what can be done here.

I have been recently diagnosed (less than a year) and on a beta blocker. I still work full time in an operating room but my fatigue recently and ability to concentrate is truly getting bad and I’m concerned about my patient’s safety obviously as well as my own. What can I mention to my PCP to help? She’s the one who diagnosed me, I’m just used to not always being taken serious since this has been on going since I was younger.

Taking beta blocker is a short term patch and is indicated in certain situations, but does not usually address the underlying root problem in the setting of AFS. Over time, dosage needs to be increased and the person feel worse because the root issue if not resolved. you should ask for someone who really understand because the longer you stay on , the harder to get off.

My daughter is 17 and her most severe symptom is air hunger or the feeling that she cannot complete a deep breath or feel the breath? I know it sounds strange but it is very hard to manage. She was diagnosed with POTS a few months ago with a table tilt test a the Cleveland Clinic. She also has chronic fatigue and Fibromyalgia. Prior to one year ago she was a very healthy active high school athlete. She is now on supplements and has been given the prescription of Fludrocortisone but, we have not yet taken it as we are trying to treat with salt and additional fluids. Does anyone else have the breathing issues, either due to tight muscles or possibly the diaphragm not working properly? She cannot understand if it is due to muscles or low blood volume? He blood pressure is not that low 120/72 with a heart rate of 63 while resting.

Feeling breathlessness despite normal pulmonary function points to the root cause of adrenergic sympathetic overtone which is consistent with POTS. Things will get worse from my experience if you do not solve the root problem. Conventional approach is very much symptoms driven. Do be very careful. I dont like to have teenagers on too much meds as not only it suppress and mask the root problem but also risks the body develop tolerance over time. Searching for esoteric clues like diaphragm is usually nonproductive , but like most parents, the need to be exhaustive is not wrong. Just be prepared that futher workup is normal and the clinical picture will get worse especially if the wrong type of supplements are used. Nothing you mentioned is unusual. We deal with this everyday in our nutritional telephone coaching . Here is an article worth your reading.Click Adrenal Fatigue Syndrome in Teenagers & Young Adults for more information. If all else fails, you can call my office and I will explain to you the physiology of what is going on so you know your option and can have an intelligent discussion with your doctor.

Just in case you still have the fillings in : Be careful not to remove the amalgams too quickly especially if you have had it for a long time because sometimes, it can trigger a massive release of mercury during the removal process that can trigger POTS.

Thank you for this article! I have one observation to make from the “Conventional Treatment of POTS” as stated above. If a person has POTS due to extreme Adrenal Fatigue and they drink a lot of water without knowing that their sodium levels are out of balance due to low levels of aldosterone and very low blood pressure, it’s not a recommendation to make. The sodium levels will drop further and make the imbalance worse, hence more symptoms. I have Adrenal Fatigue and I drink a half teaspoon of sodium in a small glass of water in the morning and salt my food well, which helps balance me out.